Abstract

The recent Department of Health announcement that nurses and other non-medical groups (with the appropriateadvanced level skills and knowledge) could be granted full prescribing rights evoked strong reaction particularly amongst the medical community.

The recent
Department of Health announcement that nurses and other non-medical groups
(with the ap-propriate advanced level skills and knowledge) could be granted
full prescribing rights evoked strong reaction particularly amongst the medical
community. Given the current pace of change in primary care organ-isations one
could be forgiven for thinking this is a step too far, too quickly, until one
reflects that the Cumberledge report first recommended nurse pre-scribing in
the interests of improving patient care over two decades ago. Familiar concerns
have arisen about nurses’ preparedness for this role and some view this
decision as a dilution of the skills of general prac-titioners and an ‘attack
on [doctors’] professional status’.[1] However, there is much
rejoicing among the many experienced primary care nurses who have long felt
that the care they provide for their patients has been compromised
unnecessarily by the limits im-posed on their prescribing.

As policy makers and managers try to balance cost containment and work
force shortages, alongside the need to improve the quality of services, the
introduc-tion of different contracting mechanisms is creating greater
diversification of models of primary care, in-cluding general practice and
further redistribution of some medical work to nurses. The competing
require-ments to increase access for patients and manage patient demand more
effectively have served to accel-erate these nursing developments, for
example, ‘first contact’ care, although the cost-effectiveness of nurse
substitution, and it’s subsequent impact on the work of general practitioners
and other health professionals (both volume and nature of workload) has yet to
be established. Nurse-led first contact care, defined as seeing patients at the
first point of contact with un-differentiated problems and managing
episodes of care by diagnosing, treating or referring is now be-coming
increasingly common place in general practice in areas such as acute/minor
illness, the on-going management of
long-term conditions and health promotion/preventative care.[2] These
activities require nurses working at the front line of clinical practice to
consult with patients autonomously in a similar way to doctors.

While many nurses have embraced these oppor-tunities with enormous
enthusiasm other nurses, in common with some in the medical profession, have
voiced concerns that by introducing advanced nursing roles in the delivery of
an ever greater range of services, the ‘essence’ of nursing may be lost,
diminishing the core nursing workforce.[3–5] Similar sentiments about
the potential loss of professional identity through the erosion of the values
of traditional family practice have also been voiced by some doctors. But what
do patients’ think about receiving care from a nurse rather than a general
practitioner, what is their per-ception of the quality of care they receive and
what aspects of the consultation do they value?

Systematic reviews of nurse–general practitioner substitution in
primary care have found that appro-priately trained nurses can produce as
high-quality care as general practitioners and achieve good health outcomes for
patients.[6–8] Patient satisfaction assessed using standard patient
questionnaires has been found to be higher following nurse consultations for
chronic disease and minor illness conditions.[6–8] Patients tend to be
more satisfied with the amount of information they receive during consultations
with nurses than with doctors and they adhere more readily to treatment recommendations
from nurses.[6–8] However, the results of these studies need to be
interpreted cautiously as they have been criticised for their narrowly
conceived definitions of and measures of patient satisfaction and their failure
to take into account previous experience and expectations.[9]

To date few studies have explored patient defined perceptions of
quality within nursing consultations. Most of these are small scale,
qualitative studies but a few key points
have emerged. Most patients find con-sulting with a nurse rather than a general
practitioner acceptable for
minor illness and some long-term con-ditions[7,10,11] but general
practitioners are preferred

when they
perceive themselves to be seriously ill. Patients are uncertain about the scope
of nurses’ first contact roles and their knowledge and competence to diagnose
and treat serious illness.[10] However, patients are frustrated at the
lack of settlement regarding nurses’ and general practitioners’ roles and
dislike nurses being unable to prescribe appropriately with-out deferring to a
general practitioner.[10] Patients’ trust general practitioners
because they believe they have had good education and training; they place
trust in nurses both as employees of the practice and because believe they have
gained experience ‘on the job’.[10]

So what do we know about what happens during nurses’ consultations with
patients that might explain why patients tend to rate them so favourably? There
is a small amount of evidence to suggest that nurses’ communication behaviours
and interactions with patients may differ from general practitioners’
con-sultations. Interview-based studies suggest that patients perceive nurses
as more communicative, they are made to feel more at
ease and are provided with more information[9,11–13] during
consultations with nurses than doctors.
Patients also tend to be more forth-coming with nurses than doctors.[13] A comparison of nurses’ and doctors’ consultations in primary care diabetes
clinics found that nurses used more expla-nations, were more inclusive of
patient opinions and patients and nurses appeared to be on a more ‘equal
footing’ whereas doctors and patients tended to be more distant from one
another.[13]

Patients have clear views about the different con-sultation
approaches of nurses and doctors. They value doctors for their skills and
knowledge in diagnosing serious illness and nurses for their rapport-building
and communication skills; these qualities are recog-nised as different
but complementary. Should we there-fore conclude that nursing and medical roles
are distinct, and that one cannot substitute for another? But where does nurse
prescribing fit within this model? The evidence is beginning to suggest that
patients’ do not just want a nurse to make them feel better; and would like
nurses to work in an auton-omous way and to be able to prescribe appropriately.
And so we need to consider another model whereby nurses’ and doctors’ roles are
complementary, some tasks are distinct and others interchangeable. But we need
to remember that whilst the professional delib-erations and lack of clarity
about nursing roles are confusing for ourselves, patients’ lack of
understand-ing is even greater. Sometime soon we ought to tell them what they
can expect from a nurse working in an advanced role.

References

Keighley B. Should nurses prescribe? British Journal of General Practice 2006;56:68.

Sibbald B, Shen J and McBride A. Changing the skill-mix of the healthcare workforce. Journal of Health Services Research and Policy 2004;9(Suppl.1):28–38.

Redsell S, Jackson C, Stokes T, Hastings A and Baker R. Nurses’ and general practitioners’ consultations: patients’ expectations for same day minor illness appointments. Final report to the Scientific Foundation Board, Royal College of General Practitioners. University of Leicester, University of Nottingham, 2005.

Collins S, Watt I, Drew P, Local J and Cullum N. Effective consultations with patients: a comparative multidisciplinary study (Full report of research activities and results for the ESRC). York: University of York, 2003.

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